Acknowledgment of Receipt of Notice of Privacy Practices
Acknowledgment of Receipt of Notice of Privacy Practices
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I acknowledge that I have received or have been provided electronic access to the Luminox Healthcare Services LLC Notice of Privacy Practices.
I understand that the Notice explains how my health information may be used and disclosed, my privacy rights, and Luminox Healthcare Services LLC's responsibilities regarding my protected health information.
- Signing this acknowledgment does not constitute authorization for any special use or disclosure of my health information and does not waive any of my privacy rights.
- I may request a paper or electronic copy of the Notice at any time.
If an acknowledgment is not obtained
HIPAA requires a direct-treatment provider to make a good-faith effort to obtain acknowledgment that the patient received the Notice of Privacy Practices. The patient is not required to sign it, and declining to sign does not amount to refusing treatment.
When an acknowledgment is not obtained, the practice documents the good-faith effort made, the date, and the reason — for example, the patient declined to sign, the acknowledgment could not be obtained, or emergency circumstances applied.